2.0 Analysis 2.1 Radar Performance Improper adjustment of the radar set could produce strong multiple/spurious echoes owing to the proximity of the two terminals or spurious but relatively weak echoes from adverse weather conditions or marine life. A proper adjustment of the radar controls can help the radar operator minimize these effects on the PPI thereby enabling him to detect closer targets. In any event, echoes from marine life cannot conceal strong radar returns from a large steel vessel, presenting a beam-on target, such as the SHINWA MARU. However, multiple echoes associated with the terminals could make it difficult to differentiate such echoes. 2.1.1 Misidentification of the SHINWA MARU One of the targets acquired on ARPA by the master of the QUEEN OF ALBERNI some four minutes before the vessel's departure was that of the SURUGA MARU, but, reportedly, the SHINWA MARU had not been acquired. Thus, a perusal of the read-out on the ARPA screen at that time should have included information on the course and speed of the SURUGA MARU or would have at least indicated a motion trend. Further, the master indicated that the SHINWA MARU was lost in the clutter and could not be identified. He, nonetheless, associated the clutter with the wake of tugs assisting a large vessel. This would suggest that the master had initially considered the clutter to have been associated with the SHINWA MARU. Nevertheless, the echo of the SURUGA MARU was apparently taken to be that of the SHINWA MARU, and the QUEEN OF ALBERNI was manoeuvred on this assumption. 2.2 Conduct of Navigation Although two radars were operational and available to the bridge team aboard the QUEEN OF ALBERNI, only one radar was used by both the master and the OOW. It is not known why the bridge personnel was unable to effectively remove the clutter on the PPI. The second radar was not utilized. As the information presented on the PPI aboard the QUEEN OF ALBERNI had not been verified against that received on the VHF R/T, crucial information was missing respecting another vessel in the vicinity that could jeopardize thesafety of the vessel. Precise information was not requested by the QUEEN OF ALBERNI from either VTS or the SHINWA MARU to positively identify the vessel on the PPI to assess risk of collision. Different persons were handling the radar and the VHF, and their efforts were not coordinated. 2.3 Situation Assessment by the QUEEN OF ALBERNI The QUEEN OF ALBERNI was steadied on a course of 240 (G), reportedly to allow two targets in the northbound traffic lane, some three to four miles away, to pass ahead, but no effective action was taken to keep clear of the SHINWA MARU, positioned barely a mile away. This would suggest that there was no immediate concern for traffic close at hand which would require prompt/timely action. While departing Tsawwassen Terminal, the bridge team on the QUEEN OF ALBERNI was aware of the presence of the SHINWA MARU and was apprised by VTS that the SURUGA MARU was located off Westshore Terminals. The distance between the Westshore Terminals and the Tsawwassen Terminal is 1.1 M, and consequently, the distance between the QUEEN OF ALBERNI and the two vessels would have been over 1 M and decreasing rapidly as the vessels gathered headway. The QUEEN OF ALBERNI neither significantly reduced speed nor stopped, either to assess the situation or to avert the already existing close-quarters situation with the SHINWA MARU. The operation of the main engines was changed from mode 2 to mode 1. The situation, as assessed by the QUEEN OF ALBERNI, was that the movement of the SURUGA MARU did not pose an immediate threat. Thus, no evasive action was considered necessary and the QUEEN OF ALBERNI inadvertently proceeded to cross ahead of the SHINWA MARU, the echo of which had not been been properly identified. However, when it was realized that no southbound vessel had been identified on the PPI and that the SHINWA MARU must indeed be within the clutter, the CP of the QUEEN OF ALBERNI was set at zero and then propulsion was reversed. 2.3.1SHINWA MARU - Lack of Assertiveness/Direction The SHINWA MARU, a fully loaded bulk carrier, constrained by her size and in the process of gaining speed, was capable of neither turning nor stopping at a rate which would significantly reduce the existing risk of collision with the QUEEN OF ALBERNI. The SHINWA MARU did not assertively direct the QUEEN OF ALBERNI to pass astern of her, in the close-quarters situation. 2.3.2 Situation Assessment by the TSB The reconstructed tracks show that, at 0806, the SHINWA MARU was about 20 on the starboard bow of the QUEEN OF ALBERNI at a range of 0.73 M. At the same time, the SURUGA MARU was some 40 on the starboard bow at a distance of about 1.25 M. With the QUEEN OF ALBERNI and the SHINWA MARU building up speed and the SURUGA MARU moving at about 3 kn, the QUEEN OF ALBERNI could not have seen appreciable change in radar vectors in a one-minute period. Further, a review of the tracks indicated that: a persistent clutter, which had reportedly precluded identification, later turned out to be the echo of the SHINWA MARU; and a second very large target just beyond the clutter had later turned out to have been the SURUGA MARU. Hence, the lack of knowledge of the relative positions of the other vessels in conjunction with the recent radio communication could likely have caused some concern aboard the QUEEN OF ALBERNI in the rapidly developing collision situation. Had the normal track been taken after leaving Tsawwassen, the QUEEN OF ALBERNI could have proceeded at a course and speed such that she would have passed astern of the SHINWA MARU and to the south of the SURUGA MARU which was manoeuvring northward toward the berth. As the VHF was monitored aboard the QUEEN OF ALBERNI, she was aware of the presence of the SHINWA MARU and the SURUGA MARU before her departure. She did not positively identify both vessels on the radar, establish their courses and speeds, and arrange safe passage before departing from the wharf. 2.4 Lack of Definitive Language Used in Communication Some two minutes before the collision, the QUEEN OF ALBERNI indicated her intention to slow down and let the SHINWA MARU pass ahead. At this stage, the pilot of the SHINWA MARU informed the QUEEN OF ALBERNI that she could pass ahead if she wanted. Thus, the apparent attempt by the QUEEN OF ALBERNI to cross ahead could probably have been influenced, in part, by the use of imprecise language that conveyed indecisiveness and was also based on scanty information. 2.5 Speed Discrepancy For all practical purposes, the speed of the SHINWA MARU as reported by her was consistent with that derived from the plot confirming the reliability of the VTC recorded positions. Once clear of the wharf, the general practice followed by the QUEEN OF ALBERNI was to increase speed. This is consistent with the change in the operation of the main engines from mode 2 to mode 1. In the absence of recorded engine movements, it is not possible to verify the precise times and corresponding CP settings from the time of the vessel's departure. While the master estimated that the QUEEN OF ALBERNI reached a maximum speed of about 8 kn, the reconstructed track of the vessel showed that, in the last two and a half minutes before the collision, the vessel averaged a speed of 15.65 kn; this despite setting the engine controls to zero about 45 to 60 seconds before the collision and eventually engaging reverse propulsion. It should be noted that the average speed of the vessel from departure at 0801 until collision at 0808 was 9.94 kn, not taking into account the time required for acceleration and the period of time that had elapsed between the CP being set to zero and the time of collision. The SHINWA MARU was not positively identified on the PPI aboard the ferry, and the collision occurred despite reverse propulsion. 2.5.1 Look-out Although three look-outs, who were positioned forward on the SHINWA MARU, heard the fog signal of the approaching QUEEN OF ALBERNI, none of them reported it to the bridge. It is not known why the bridge personnel on board the QUEEN OF ALBERNI neither heard the sound signal from the approaching SHINWA MARU nor acknowledged receipt of the fog signal reported by the forward look-out. 2.5.2 Use of Very High Frequency Radiotelephone for Collision Avoidance The bridge teams on both vessels did not exercise caution, nor did they make greater and more effective use of other available means to ascertain risk of collision. Instead, they mainly relied on the information obtained by VHF R/T and a presumed mutual understanding. It should be noted that instances are on record wherein improper and solitary use of VHF R/T by either one or both vessels in an attempt to avoid collision has proven dangerous. On the other hand, VHF R/T, when properly used in conjunction with other aids to navigation and in compliance with the COLREGS, can enhance safety. Hence, when VHF R/T is used for collision avoidance purposes, extreme caution must be exercised to ensure that: both vessels are positively identified; precise and unambiguous language as contained in the Standard Marine Navigational Vocabulary is used at all times; passing arrangements are made in ample time to ensure that valuable time is not wasted; and the course of action is in compliance with the COLREGS. 2.6 Perception and Decision Making Ferries transport large numbers of passengers and vehicles and operate on tight schedules, a situation which can create a sense of underlying pressure to maintain the schedule, and masters constantly endeavour to avoid delays, as much as possible. Once delayed, it would be difficult for a ferry to regain her schedule for the day. It cannot be determined if the consequences of any delay was one of the issues influencing the master's decisions. In this instance, the fact that the pilot of the SHINWA MARU indicated to the master of the QUEEN OF ALBERNI that the latter could pass ahead if he so desired, may have led to a tendency for the threat posed by the close-quarters situation, as perceived by the master of the QUEEN OF ALBERNI, to be somewhat downplayed. Since the distance separating the two vessels was less than a mile, by the time the danger was realized, collision was imminent. 3.0 Conclusions 3.1 Findings The QUEEN OF ALBERNI departed from her berth in reduced visibility after the SHINWA MARU had sailed from an adjacent terminal. The QUEEN OF ALBERNI took a more southerly course than her normal track. The course chosen by the QUEEN OF ALBERNI exacerbated the close-quarters situation with the SHINWA MARU. The QUEEN OF ALBERNI did not positively identify the SHINWA MARU on radar and incorrectly assumed that the echo of the SURUGA MARU was that of the SHINWA MARU. The QUEEN OF ALBERNI, proceeding at an average speed in excess of 15 knots prior to the collision, did not request from either Vessel Traffic Services (VTS) or the SHINWA MARU precise information on the latter's position to enable her to be positively identified on the plan position indicator (PPI). The apparent absence of the second echo on the PPI aboard the QUEEN OF ALBERNI was not questioned. The information as presented on the radar aboard the QUEEN OF ALBERNI was not verified against the information received on very high frequency radiotelephone (VHF R/T). The precise manoeuvring terminology in the Standard Marine Navigational Vocabulary was not used, and neither vessel made decisive passing arrangements. The use of imprecise language and the misidentification of the SHINWA MARU tended to downplay somewhat the threat posed by the risk of collision on board the QUEEN OF ALBERNI. The SHINWA MARU was constrained by her size, and the pilot was not assertive in directing the QUEEN OF ALBERNI to pass astern. Both vessels relied exclusively on the passing arrangement made on VHF R/T, contrary to procedures as defined in the International Regulations for Preventing Collisions at Sea (COLREGS). There was virtually no change in the bearing between the two vessels as they approached each other. No follow-up action was taken by the master or officer of the watch (OOW) of the SHINWA MARU with regards to the developing situation. There was some delay in evacuating the injured passengers from the ferry as no person was designated to expedite the efforts of the emergency response teams. 3.2 Causes The QUEEN OF ALBERNI and the SHINWA MARU collided in dense fog because all available means were not used by both vessels to assess risk of and avert collision in a rapidly developing close-quarters situation. 4.0 Safety Action 4.1 Action Taken 4.1.1 Emergency Planning Following this occurrence, the TSB forwarded a Marine Safety Advisory to the Canadian Coast Guard (CCG) regarding the need for a coordinated emergency response plan to interact with external emergency teams in organizing and evacuating injured passengers on passenger ferries. In April 1992, the British Columbia Ferry Corporation (BCFC) carried out a review of its operational procedures with a view to improving passenger and crew safety. In conjunction with the CCG, the BCFC reviewed the capability of its crews to deal with emergency situations. Existing training programs were also reviewed and new ones developed to prepare all employees to cope with emergency situations. In addition, in its report on a separate occurrence between the ferry WOODSIDE I and the tug TUSSLE (TSB Report #M90M4053), the Board noted similar safety deficiencies in emergency procedures and recommended that the Department of Transport require that officers and crew members of all federally inspected ferries and passenger vessels receive formal training on crowd control and relevant emergency procedures (M93-07, issued March 1993). In its response, Transport Canada indicated that certificated ships' officers and ratings form a core of formally trained personnel which, in conjunction with the master's responsibility to organize and train the entire crew, should enable abandonment to take place safely. The reply made no mention of formal training on crowd control and relevant emergency procedures being considered for all crew members. 4.1.2 Operational Review - Radar Training The aforementioned BCFC operational review also identified the need for SEN/ARPA (Simulated Electronic Navigation/Automatic Radar Plotting Aid) training for bridge crews on the use of radar during periods of restricted visibility. It is understood that all BCFC deck officers who have not already taken the SEN/ARPA courses now receive training at marine schools. In addition, the BCFC has developed a two-day radar/ARPA refresher workshop for its ferry masters. 4.1.3 Use of Standard Marine Navigational Vocabulary Investigations on several occurrences similar to this one revealed that an inadequate or improper use of marine navigational vocabulary in ship radiocommunications had led to dangerous situations. Therefore, the Board recommended that the Department of Transport promote an increased awareness and use of the Standard Marine Navigational Vocabulary (TP 4330) within Canadian waters (M93-05, issued June 1993). In March 1994, a Ship Safety Bulletin (SSB No. 5/94) was issued on the need for effective communications between vessels. The SSB urged ship operators and navigating personnel to make full use of the CCG publication, Standard Marine Navigational Vocabulary, TP 4330. The SSB also advised that the revised Charts and Publications Regulations will require the carriage of this publication on Canadian vessels.